- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,202.26 / $1,698.24
| Professional | | $758.58 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $1,380.38 / $2,454.71
| Facility | | $138.04 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $1,148.15 / $1,621.81
| Professional | | $154.88 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $489.78
| Facility | | $467.74 | $467.74 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $398.11 / $467.74
| Professional | | $104.71 | $398.11 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $691.83 / $1,258.93
| Facility | | $154.88 | $691.83 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,202.26 / $1,698.24
| Professional | | $758.58 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $1,096.48
| Professional | | $81.28 | $109.65 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,148.15
| Professional | | $1,071.52 | $1,071.52 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,548.82 / $1,548.82
| Professional | | $1,148.15 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $446.68 / $1,023.29
| Facility | | $51.29 | $446.68 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $602.56 / $954.99
| Professional | | $512.86 | $602.56 | $954.99 |